P1.215: Clinical Event Debriefing of Neonatal Resuscitation: Qualitative Results from a Multicenter Pilot Study

Background: Clinical event debriefing (CED) is an important tool that helps healthcare teams identify strengths, address weaknesses, and formulate improvement strategies following patient care events delivering patient care. The Neonatal Resuscitation Program® endorses post-resuscitation debriefings to improve team performance and patient outcomes. In this study, we aimed to qualitatively analyze the strengths, weaknesses, and action plans discussed during clinical event debriefings following neonatal resuscitation events in delivery rooms and neonatal intensive care units (NICUs) across three academic institutions.

Methods: A 17-member American Academy of Pediatrics (AAP) taskforce developed and iteratively revised the “Who, What, When, Where, Why and How in CED” (WHiCED) framework for clinical event debriefing. This structured approach was piloted across three academic centers. Teams conducted debriefings following neonatal resuscitation events in delivery rooms and NICUs. Observations were entered into a centralized online repository and analyzed qualitatively. Two independent taskforce members coded the data and performed thematic analysis to identify recurring patterns.

Results: Twenty-four debriefings were conducted over a two-month period (December 2022–February 2023). Most debriefings (76%) occurred within one hour of the event and lasted fewer than 10 minutes. Teams identified 40 strengths (Table 1), 44 weaknesses (Table 2), and 22 action plans (Table 2). Most discussion points centered on behavioral domains—such as teamwork, communication, and role clarity—rather than technical clinical care. Simulation and ongoing professional development were often proposed as methods to reinforce strengths and address identified weaknesses.

Conclusion: Behavioral competencies—including communication, teamwork, and situational awareness—dominated the findings from post-resuscitation debriefings. Enhancing Neonatal Resuscitation Program® curricula to emphasize these behavioral elements may strengthen team performance. Standardized implementation of the framework and shared data collection across institutions can facilitate targeted training and inform quality improvement strategies in neonatal resuscitation.